Kaan Irgit

Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture.

OBJECTIVE Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application. METHODS From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded. RESULTS The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage. CONCLUSIONS The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.

Locked Plating of Periprosthetic Femur Fractures Above Total Knee Arthroplasty

Background: Fractures of the femur above a total knee arthroplasty (TKA) are becoming increasingly common in the osteoporotic, aging populations of developed countries. Treatment of these fractures is complicated by the presence of a knee prosthesis, frequently limiting the bone available for distal fracture fixation. The recent application of minimally invasive surgical techniques and locked plate technology to this problem offers the promise of stable, fixed-angle fixation of small distal fracture fragments with limited surgical exposure. The purpose of this study is to report the clinical and radiographic outcomes of fracture fixation using this technique in patients with periprosthetic femur fractures above TKA. Methods: Fifty-three patients presenting with periprosthetic femur fractures above a TKA were treated with osteosynthesis. One patient was lost to follow-up resulting in 52 patients with complete data. Thirty-four patients were treated with plate fixation and 18 patients underwent retrograde intramedullary nail fixation (RIMN). Using a comprehensive electronic medical record, we recorded data regarding patient-related demographics, nature of the fractures, the operative treatment, and clinical and radiographic outcomes for all patients treated with osteosynthesis. Results: Successful fracture healing occurred in 75% of patients (39 of 52). Mean operating time was 91.6 ± 6.8 minutes in the RIMN group and 87.4 ± 6.4 minutes in the locked plating (LP) group (P = 0.46). Mean intraoperative blood loss was 182 ± 31.6 mL in the RIMN group and 177.5 ± 23.4 mL in the LP group (P = 0.91). The mean time to bone union was 3.7 ± 0.30 months in the RIMN group and 4.0 ± 0.27 months in the LP group (P = 0.95). The most common cause of treatment failure was patient death within 6 months (9 patients [17%]); three of 18 were treated with a nail and 6 of 34 with a plate (P = 1.0). In the LP group, three (9%) sustained fracture nonunions, three (9%) sustained fracture malunions, and two (6%) sustained surgical site infections. In the RIMN group, one (6%) failed to unite as a result of infection and two (11%) developed fracture malunions. There were no significant differences between patients treated with LP and those treated with RIMN. Conclusions: Despite significant advances in surgical technique and implant design, the treatment of periprosthetic femur fractures above a TKA remains a challenge. LP using an indirect reduction technique is applicable to most patients and prosthetic designs and can provide similar favorable results as compared with treatment with a RIMN in periprosthetic femoral fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes and complication rates of different bone grafting modalities in long bone fracture nonunions: a retrospective cohort study in 182 patients

BackgroundNovel bone substitutes have challenged the notion of autologous bone grafting as the ‘gold standard’ for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones.MethodsA retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting.ResultsThe autograft cohort had a statistically significant shorter time to union (198 ± 172–225 days) compared to allograft (416 ± 290–543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159–619 days) or rhBMP-2 (217 ± 158–277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05).ConclusionAutologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.

Reverse Total Shoulder Arthroplasty in Obese Patients

PURPOSE To determine function and complications after reverse total shoulder arthroplasty (RTSA) in obese patients compared with a control group of nonobese patients. METHODS Between 2005 and 2011, we performed 76 RTSAs in 17 obese, 36 overweight, and 23 normal weight patients, based on World Health Organization body mass index classification. We reviewed the charts for age, sex, body mass index, date of surgery, type of implant, type of incision, length of stay, comorbidities, surgical time, blood loss, American Society of Anesthesiologists score, shoulder motion, scapular notching, and postoperative complications. Complications and outcomes were analyzed and compared between groups. RESULTS Reverse total shoulder arthroplasty in obese patients was associated with significant improvement in range of motion. Complication rate was significantly greater in the obese group (35%), compared with 4% in the normal weight group. We found no significant differences between scapular notching, surgical time, length of hospitalization, humeral component loosening, postoperative abduction, forward flexion, internal and external rotation, pain relief, or instability between groups. CONCLUSIONS Our results show that obese patients have significant improvement in motion after RTSA but are at an increased risk for complication. Obesity is not a contraindication to RTSA, but obese patients need to understand fully the increased risk of complication with RTSA. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Treatment of interprosthetic fractures of the femur.

BACKGROUND The treatment of interprosthetic femoral fractures is challenging because of several factors. Poor bone stock, advanced age, potential prosthetic instability, and limited fracture fixation options both proximally and distally can complicate standard femur fracture treatment procedures. The purpose of this report was to describe our experience treating interprosthetic femoral fractures, providing an emphasis on treatment principles and specific intraoperative management. METHODS All patients with fractures occurring between ipsilateral hip and knee prostheses between 2004 and 2010 were identified from a comprehensive database and included in this study. Patients had been treated using principles adapted from two isolated periprosthetic fracture classification systems, the Vancouver and Su classifications. The electronic medical record (including inpatient medical records, operative notes, outpatient medical records, and all radiographs) was reviewed for each patient and demographic and treatment-related variables as well as complications and outcomes were recorded. RESULTS Thirteen consecutive patients with interprosthetic fractures were included. Four fractures occurred around a clearly loose prosthesis, which were subsequently treated with long-stemmed revisions. The remaining 12 fractures were treated with a locked-plate construct. Two of nine patients (22.2%) died before fracture union. Follow-up averaged 28 months ± 4 months, with fracture union achieved at an average of 4.7 months ± 0.3 months. All patients returned to their self-reported preoperative ambulatory status except one who developed a loose hip prosthesis at 3-year follow-up after fracture union. CONCLUSIONS The principles for treatment of isolated periprosthetic fractures are useful to guide the fixation of interprosthetic fractures. Locked plating is an effective method for the treatment of interprosthetic femoral fractures. Bypassing the adjacent prosthesis by a minimum of two femoral diameters is a necessary technique to prevent a stress riser.

Drop foot after knee dislocation: evaluation and treatment.

Although knee dislocations are relatively rare, serious complications make treatment difficult. Common peroneal nerve (CPN) palsy is a debilitating complication and its incidence has been reported as high as 50%. Even after successful ligament construction, unresolved CPN palsy is a major factor contributing to poor outcomes after knee dislocations. CPN palsy is more common with open dislocations, rotatory dislocations, and especially occurs in patients with posterolateral corner injuries. CPN palsy can be readily diagnosed clinically, although a high index of suspicion is needed. The risk versus benefits of surgical exploration in the acute setting is still under debate. Conservative management can be appropriate in the early phase of treatment, however, for persistent nerve damage, surgery is the treatment of choice because it results in better functional outcomes. Neurolysis, primary nerve repair, nerve grafting, and posterior tibialis tendon transfer have all been used by surgeons as viable surgical treatment options. As late surgical treatment of CPN typically results in poor prognosis, awareness of this injury, thorough physical examination and documentation of the nerve injury, and close follow-up are of paramount importance.

Defining Racial and Ethnic Disparities in THA and TKA

BackgroundFor minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA.Questions/purposesWe therefore (1) defined utilization disparities for total joint arthroplasty in racial and ethnic minorities, (2) delineated patient and provider factors contributing to the lower total joint arthroplasty utilization, and (3) discussed potential interventions and future research that may increase total joint arthroplasty utilization by racial and ethnic minorities.MethodsWe searched the MEDLINE database and identified 67 articles, 21 of which we excluded. By searching Google and Google Scholar and reference lists of the included articles, we identified 40 articles for this review. Utilization disparities were defined by documented lower utilization of THA or TKA in specific racial or ethnic groups.ResultsLower utilization of THA and TKA among some racial and ethnic minority groups (African Americans, Hispanics) is not explained by decreased disease prevalence or disability. At least some utilization disparities are independent of income, geographic location, education, and insurance status. Causal factors related to racial and ethnic disparities may be related in part to patient factors such as health literacy, trust, and preferences. Provider unconscious or conscious biases or beliefs also play a role in at least some healthcare disparities.ConclusionsRacial and ethnic THA and TKA utilization disparities exist. These disparities are not explained by lower disease prevalence. The existing data suggest patient education, improved health literacy regarding THA and TKA, and a patient-provider relationship leading to improved trust would be beneficial. Research providing a better understanding of the root causes of these disparities is needed.

Treatment of pertrochanteric fractures (OTA 31-A1 and A2): long versus short cephalomedullary nailing.

Objectives: To retrospectively compare the clinical outcomes in patients with pertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1 and A2) after treatment with short or long cephalomedullary nails. Design: Retrospective study. Setting: Academic level I trauma center. Patients: Two hundred eighty three adult patients presenting with simple or multifragmentary pertrochanteric femur fractures (OTA 31-A1 and A2) between 2004 and 2009 qualified for inclusion in this study. Intervention: One hundred patients were treated with a short cephalomedullary nail and 183 with a long cephalomedullary nail. Main Outcome Measurements: Patient demographics and medical comorbidities were recorded for each patient via an electronic medical record. Treatment-related variables including the American Society of Anesthesiologists (ASA) score, duration of surgery, volume of intraoperative blood loss, need for blood products, treatment-related complications, and mortality were recorded and compared between the short and long nail groups. Results: There were no significant difference between treatment modalities, complication, and reoperation rates for the 2 groups. Treatment with a long nail resulted in subtle increases in procedure time and blood loss. Conclusions: No differences in the union and complication rates between the 2 groups were identified, suggesting that long nails offer no advantage compared with short nails for stabilizing simple and multifragmentary pertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1 and A2). Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality

The purpose of this study was to examine the acute outcomes and mortality rates of an Advanced Trauma Life Support guideline approach for managing hemodynamically unstable pelvic ring injuries. We retrospectively reviewed the acute outcomes of 48 consecutive patients with hemodynamically unstable pelvic fractures. Patients underwent treatment via the advanced trauma life support protocol, with primary angiography based on trauma surgeon preference. Mean patient age was 51.2 years, with a mean injury severity score of 43.2±14.3. Mean systolic blood pressure was 74.8±16.1 mm Hg at presentation. Patients received an average of 7.0±6.6 units of red blood cells and 4.2±2.3 units of fresh frozen plasma in the first 6 hours. Fourteen patients underwent emergent angiography, and 12 patients were treated with embolization. Mean time to angiography was 3 hours and 55 minutes (range, 2-19 hours). Twenty patients died during hospitalization, with an overall mortality rate of 41.7%; 13 (27.1%) of them died within 24 hours. Advanced Trauma Life Support guidelines with angiography are not adequate for the management of hemodynamically unstable pelvic ring injuries and result in unacceptably high mortality rates compared with more specific approaches using transfusion protocols and interventions, such as pelvic packing.

Stemmed femoral implants show lower failure rates in revision total knee arthroplasty

BACKGROUND Stemmed femoral implants are not universally used in revision total knee arthroplasty. The aim of this study was to evaluate whether the re-revision rate would be greater for revision total knees performed without stemmed femoral implants compared with revision total knees performed with stemmed femoral implants. METHODS All revision cases performed at a single institution between 2004 and 2011 were retrospectively reviewed. A total of 130 revision total knee arthroplasty procedures (63 Group 1; 67 Group 2) met the inclusion criteria. RESULTS Revisions performed without femoral stems failed more often than revisions with femoral stems (44% vs 9%, p<0.001) despite more severe pre-operative bone loss in groups that were revised with stems (p<0.05). CONCLUSIONS We recommend that femoral stems be used routinely in procedures where a femoral implant is revised following a prior total knee arthroplasty.